A Few Thoughts on “Culture” in Healthcare

The big news in Boston healthcare last week was the announcement that Tufts and Boston University Medical Centers were calling off their proposed merger. The Boston Globe wrote:

Although they did not specify why the deal fell apart, the hospitals were apparently unable to overcome differences in culture, mission, and strategies for the future, analysts said. “Culture always trumps strategy,” said Ellen Lutch Bender, president of the consulting firm Bender Strategies LLC.

I don’t know any of the details about the proposed merger, and certainly can’t tell you if the deal made sense. But it also wouldn’t be the first partnership that failed due to perceived incompatibilities in organizational culture. In fact, one of the great healthcare case studies in business school is about the ultimately failed merger of Stanford and UCLA health systems– a marriage that came apart after two years. The cause, according to the Stanford Alumni Magazine?

The venture’s biggest downfall may have been that it never managed to bind the two institutions together with a common culture.

I’ve been thinking a lot about the concept of culture in healthcare. You hear the term used frequently– generally to describe either some sort of social incompatibility between one group and another. Besides mergers, the other time you hear the term used is to explain poor operational performance at healthcare organizations. People in healthcare often finger “culture” as the explanation for a litany of disappointing outcomes, failed initiatives and poor performance.

As examples– you frequently hear of the Veteran’s Administration (VA) and the UK National health Service (NHS) as organizations with cultures that need to be fixed. As much as colleagues (who know these organizations far better than me) will more readily implicate a lack of resources, staffing shortfalls and dysfunctional systems as the main causes for their pain– you’ll often see articles referencing the VA’s lackadaisical “culture” as the primary cause for the misrepresentations, falsified documents and operational problems at the agency.

Rob Nabors, a former deputy chief of staff for Mr. Obama who was sent to work with the department, wrote last summer that a “corrosive culture has led to personnel problems across the department that are seriously impacting morale and, by extension, the timelines of health care.”

The Washington Post commented that “changing the VA’s culture [is] harder than selling soap” (a reference to Bob MacDonald, the new head of the VA and the retired CEO of Proctor and Gamble.

You’ll see a similar line of attribution in the UK. There, multiple whitepapers examining the National Health Service in the UK (over the past twenty years!) have apparently concluded that “achieving meaningful and sustainable quality improvements in the NHS requires a fundamental shift in culture.”

For all the talk of culture in healthcare, It strikes me that we healthcare managers are probably a little glib in throwing the term around. After all, organizational psychologists and anthropologists have made entire careers out of studying cultures and I have no doubt that the layman’s loose use of the term must make them nuts.

I recently stumbled across an excellent article, a review of culture as it pertains to healthcare quality, written by Dr. Huw Davies, Professor of Health Care Policy and Management at the University of St. Andrews and colleagues. Davies makes the point that there is a huge amount of controversy in the field regarding the definition and nature of healthcare culture.

The first point Davies makes is that there is significant academic controversy concerning culture as something that groups either have or are.Is culture a set of modifiable beliefs and actions that can be affected to improve the quality of healthcare in some way? Davies writes:

This distinction is crucial for, if culture is something that an organisation has, then it may be possible to create, change, and manage culture in the pursuit of wider organisational objectives. However, if organisations simply are cultural entities, then their study may help us to understand the processes of social construction at work but offers less in terms of shaping change or assisting with management control.

In other words, in healthcare we’ve convinced ourselves that our efforts at cultural transformation (by hiring leaders such as Rob Nabors) will result in cultural and then the operational change we desire. Davies argues that this isn’t a given. This isn’t to say that culture doesn’t change over time– but that it’s likely more sticky and complex than we’d hope. Worse, the relationship between culture and operational success is “equivocal, at best.”

Davies makes two critical points about cultures in healthcare:

First is that in most organizations there are often multiple sub-cultures at work. The two dominant cultures in most organizations are those of health managers and physicians. Here is how the two systems fundamentally differ:

As a corollary, these are a limited number of ways that organizations can manage competing subcultures. They can fit synergistically— a melding or cultures with the combination greater than the sum of its parts. One culture can dominate the other. There can be separation of cultures. Or there can be breakdown, where a culture refuses to acquiesce to another and conflict results.

I’d argue that every time I’ve been in an organization that was trying to improve culture (really, in most places a euphemism for trying to change the belief systems of physicians to make them more similar to those of healthcare executives) we’ve ended up hoping for synergy but usually stuck as either: 1) separate systems or 2) with the doctors dominated by administration or 3) in the midst of a cold war.

The other point Davies makes is that all of the work that we are undertaking to improve transparency, cost, top-of-license work and systems performance implicitly requires physicians to modify many core beliefs. It’s an astute and important point.

Here are my takeaways:

Assuming you believe that culture can be changed through leadership (and I simply don’t know if this is true…), then:

1) The most important conflict in healthcare right now is the clash between physician and administrator cultures. Bridging this gap– creating synergy between the two value systems– will be the primary challenge at most organizations.

1b) As a corollary: when people talk about “cultural” mismatch between two merging organizations, they are likely referring to a discrepancy between the degree to which physicians vs. medical administrators comprise each organization’s defining culture.

2) Cultural change will be accompanied by significant resistance, and needs to be done selectively by deciding which aspects of culture to keep and which to change. Much of physician culture (the primacy of patients, personal accountability, etc… is actually to be envied by other professions).

3) Cultural change can’t be done in isolation, and needs to be accompanied by real work in the areas of reporting, strategy, finance and operations.

Davies concludes his superb article with a warning:

Recognizing that cultures do change need not imply that cultures can be changed in a predictable manner by policy or managerial interventions. Indeed, observations in other industries suggests that one of two circumstances must pertain if fundamental change is to be achieved: either the organization must be facing imminent crises leading to possible extinction or there must be considerable organizational slack available.

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“Managing capitation can be deceiving. Like flying an airliner, the gauges, levers and controls can make it seem like high-stakes science. It is, partly. But as with all things healthcare this is ultimately about humans, their needs and their behaviors. You eventually learn that managing the payment model is as much an art as is the actual practice of medicine”.